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238 Danner Road Lot 45 • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 �0? Account #: 989900284 Tax PIN/EH#: 5820-65-15549.45 Billed To: Piedmont Triad Construction Subdivision Info: Pepperstone one Lot#45 Reference Name: Location/Address: Danner Road-27028 Proposed Facility: Residence Property Size: 265x116 ATC Number: 2570 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE CO ON IS V D FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Sign e: Date: 6eolroomS CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 1o S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO as arantee that the system will function satisfactorily for any given period of time. 130' N \nom y. �1 OVA Septic System Installed By: TA Environmental Health Specialist's Signature: Date: j D DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT ~ Environmental Health Section , P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900284 Tax PIN/EH#: 5820-65-15549.45 Billed To: Piedmont Triad Construction Subdivision Info: Pepperstone one Lot#45 Reference Name: Location/Address: Danner Road-27028 Proposed Facility: Residence Property Size: 265x116 Vber: 2570 **NOT R*' s improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type flMN5C #People #Bedrooms 3 #Baths 2- Dishwasher: Dishwasher: 0- Garbage Disposal: ❑ Washing Machine: GZ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ � t 22''^^ Lot Size 11(�x 23 Type Water Suppl Bl Design Wastewater Flow(GPD) �. J Site: New Repair❑ System Specifications: Tank Size! CC AL. Pump Tank GAL. Trench Width 'Xe Rock Depth 12„Linear Ft. 0t Other: \ o lsTQ� l O� J� ��SS TO Lt, U 1 b•C. µt rJ. Required Site Modifications/Conditions: f�1 Ey ©� �-�Otxz, VEEP 1 aoyT- Pet-P. L•,-3ct IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 u BELOW FINISHED GRADE. ”"NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** IC6 k "x4f—" t 0.c, 1 loo, V Environmental Health Specialist's Signature: Date: f �0 DCHD 05/99(Revised) - rr ERAPPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&Davie County Health Department Environmental Health Section P.O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed le '7h Tko Contact Person , 'i".reegrical Mailing Address e brleo U Rome Phone %�o�-� .1,01erl city/state/ZIP �1cksy - `�`lea 8naineaa Phone `]_ 2. Name on Permit/ATC if Different than Above Mailing Address city/state/zip 3. Application For: ❑ Site Evaluation - Improvement Permit/ATC .tie 4. system to service: rh"H-ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms 3 # Bathrooms LYD��iahwashar ❑ Garbage Disposal awashing Machine 0 Basement/Plusbing O Basement/No Plumbing 6. If Business/Induatzy/Other: specify type # People # sinks # Commodes # showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: UK-county/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes "0 If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION. Property Dimensions: .� Z (, WRITE DIRECTIONS(from Mocksville)to PROPERTY: /dj )&Y.SAM �O Tax Office PIN: # ,� 8r�� --��r I.�5�9 • y� f� Property Address: Road Name AD hh yell �G' l�h hqX �1,11OZ4,h City/Zip �) S At- -a 11'ek eA!( DA If in a Subdivision provide Information,as follows: D / Oji et, Name: &defS160 Section: Blocks Lot: r Date Property Flagged: g— /9 —4 C3 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) Issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or If the information submitted in this application is falsified or changed 1,also,understand that I am responsible for all charges Incurred from this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. V. DATE ''f o� U 10 r SIGNATURE THISAREA Y'B USED FOR DRAWING YOUR SITE P (Include all of the following: Existing and proposed property lines a d di ensions, structures, setbacks, and septic locations). Site Revisit Charge G Date(s): Client Notification Date: ? 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